Psychiatric medications, science, marketing, psychiatry in general, and occasionally clinical psychology. Questioning the role of key opinion leaders and the use of "science" to promote commercial ends rather than the needs of people with mental health concerns.

Wednesday, May 07, 2008

It appears that the massive bipolar awareness campaigns from NAMI and various drug companies have paid off big time. The conclusions of a new study by Mark Zimmerman and colleagues in the Journal of Clinical Psychiatry state, in part:

However, our results suggest that overdiagnosis of bipolar disorder is as much, if not more, of a problem than underdiagnosis.

Say what? Well, if you've been following the mental health world, you may have noted that bipolar disorder is the new plague -- it is apparently spreading like wildfire. David Healy wrote an excellent article in PLoS Medicine in 2006 which has been validated by Zimmerman et al.'s latest study. Healy wrote in part:

One of the most famous direct-to-consumer television adverts for a drug begins with a vibrant woman dancing late into the night. A background voice says, “Your doctor probably never sees you when you feel like this.” The advert cuts to a shrunken and glum figure, and the voiceover now says, “This is who your doctor usually sees.” Cutting again to the woman, in active shopping mode, clutching bags with the latest brand names, we hear: “That's why so many people with bipolar disorder are being treated for depression and not getting any better—because depression is only half the story.” We see the woman again depressed, looking at bills that have arrived in the post before switching to seeing her again energetically painting her apartment. “That fast- talking, energetic, quick tempered, overdoing it, up-all-night you,” says the voiceover, “probably never shows up at the doctor's office, right?”

No drugs are mentioned. But viewers are encouraged to log onto www.bipolarawareness.com, which takes them to a Web site called “Bipolar Help Center,” sponsored by Lilly Pharmaceuticals, the makers of olanzapine (Zyprexa). The Web site contains a “mood disorder questionnaire” (http:/​/​www.bipolarhelpcenter.com/​resources/​mdq.jsp). In the television advert, we see our heroine logging onto www.bipolarawareness.com and finding this questionnaire. The voice encourages the viewer to follow her example: “Take the test you can take to your doctor, it can change your life….getting a correct diagnosis is the first step in treating bipolar disorder. Help your doctor to help you.”

This advert markets bipolar disorder. The advert can be read as a genuine attempt to alert people who may be suffering from one of the most debilitating and serious psychiatric diseases—manic-depressive illness. Alternatively, the advert can be read as an example of what has been termed disease mongering. Whichever it is, it will reach beyond those suffering from a mood disorder to others who will as a consequence be more likely to see aspects of their personal experiences in a new way that will lead to medical consultations and in a way that will shape the outcome of those consultations. Adverts that encourage “mood watching” risk transforming variations from an emotional even keel into potential indicators of latent or actual bipolar disorder. This advert appeared in 2002 shortly after Lilly's antipsychotic olanzapine had received a license for treating mania. The company was also running trials aimed at establishing olanzapine as a “mood stabilizer,” one of which was recently published.

Here's part of an Abilify for bipolar ad...

Back to the Zimmerman study. The researchers interviewed 700 patients with the Structured Clinical Interview for DSM-IV (SCID). Keep in mind that the SCID is not a conservative measure. When patients receive an unstructured interview, they tend to receive fewer diagnoses than when they are interviewed with the SCID, which makes sense because the SCID sticks to asking detailed questions about DSM-IV symptoms, whereas most interviews ask questions about a variety of topics, and don't go into nearly as much depth regarding one's DSM-specific symptoms.

These 700 patients were also asked if they had been diagnosed as bipolar by a healthcare professional. 145 of the 700 patients included in the study indicated they had been diagnosed as bipolar. Then it gets interesting...

Of the 145 patients diagnosed as bipolar prior to being interviewed for the present study, only 63 (43.4%) were labeled as having bipolar disorder according to the SCID. Remember, the SCID tends to generate more diagnoses than a typical clinical interview, so it's not like the SCID is generally insensitive to picking up on DSM-IV disorders. The researchers even took the liberty of diagnosing many patients who did not officially meet bipolar I or bipolar II diagnostic standards as having bipolar NOS (not otherwise specified); about 25% of those diagnosed with bipolar according to the SCID were labeled as having bipolar NOS. In other words, the authors of the study went out of their way to be quite inclusive, to label some cases that did not quite meet DSM-IV criteria for bipolar as bipolar NOS. So one cannot reasonably state that they were being too restrictive with how they made their bipolar diagnoses.

To put it straight: Over half of the patients coming into the study with a bipolar diagnosis were not labeled as bipolar in the present study when given a thorough diagnostic interview.

Naysayers.Of course, the "bipolar spectrum" club will unite to say that this article is junky. I read an email from a psychiatrist who stated that the study was flawed because the DSM-IV model of diagnosing bipolar is wrong; it is too restrictive. But since the current researchers went past official DSM-IV criteria to make some of their bipolar diagnoses, I'm not sure that is a very valid concern. But similar points will be raised over and over again. Those in favor of expanding the boundaries of bipolar disorder will insist that all this study showed was that the DSM needs change; it needs to broaden its definition of bipolar disorder. Those who were diagnosed as having bipolar disorder but were not labeled as such according to a thorough interview based on the DSM -- those people had "subthreshold" bipolar disorder, which will be labeled as an "underdiagnosed and undertreated" condition that needs to be remedied through more Awareness Days and the like. Doubt me? A group of researchers recently stated that "subthreshold bipolar disorder" was not receiving the treatment it needed, a claim they later retracted when it was pointed out that there was not a single shred of evidence to suggest that such a "condition" received any benefit from treatment with mood stabilizers or antipsychotics.

Why did bipolar become so hip? Mark Zimmerman, lead author of the present study is no pharma hater. By that, I'm not suggesting that he's in bed with pharma either; I'm just saying that he has no axe to grind. So how did he interpret his team's findings?

The impact of marketing efforts and publicity probably also plays a role. Direct-to-consumer advertisements that refer individuals to screening questionnaires can result in patients suggesting to their treaters that they have bipolar disorder. We have seen evidence of this in our practice...

We hypothesize that the increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is medication responsive. The bias is reinforced by the marketing message of pharmaceutical companies to physicians that has emphasized the literature on the delayed recognition and underrecognition of bipolar disorder, and may be sensitizing clinicians to avoid missing the diagnosis of bipolar disorder. The campaign against underrecognition, which is also illustrated in the titles of published articles in peer-reviewed journals, has probably resulted in some anxious, agitated, and/or irritable depressed patients who complain of insomnia and "racing thoughts" being misdiagnosed with bipolar disorder.

The Last Psychiatrist has also been duly keeping tabs on the bipolar epidemic (1, 2, 3) and I recommend reading his posts on the topic. To quote from one of them:

Yes, but even though the world agrees the symptoms are the same, the consequences of each label is very different, right? The epidemiology, the prognosis-- the meds?

But the real difference is the societal implications. Getting a diagnosis changes the way you relate to the world, and the world relates to you. The label changes your identity and how you think.

Don't agree? Try killing someone and using "pervasive ADHD" as a defense. Get it?

We pretend that psychiatry is an emerging science, and hide behind a feigned ignorance ("we don't know everything, but we're making progress!") And so no one has to take responsibility, or even admit, that psychiatry is changing the evolution of humanity, right in front of our eyes, with nothing more than words.

Right. We relabel conditions and act as if we just figured out the laws of relativity. It's not ADHD or conduct disorder or borderline personality or anger management issues or just, life sucks for you right now and you're having a difficult time adjusting to life's difficulties -- it's... bipolar disorder! Look at the progress we've made! But where is the data showing that these people who are being newly christened as bipolar are actually doing any better due to their new label and their new course of treatment? Doesn't giving someone a bipolar label impact that person? I'd probably feel differently about life if a medical authority labeled me as bipolar.

So I propose that we start a Bipolar Overawareness Week, complete with a website linking to a questionnaire that makes statements like:

Do you know that your symptoms are probably not indicative of bipolar disorder?

Ask your doctor if you've been misdiagnosed with bipolar.

Find out if you are unnecessarily taking Zyprexa today.

Let's see if we can get the National Alliance for the Mentally Ill on board. Surely they want to make sure that patients receive the proper diagnosis. Surely drug companies, with their interest in good science and good medical practice, want to help out as well, since they want to make sure that their drugs are prescribed properly.

12 comments:

Good post. The jargon term for "disease mongering" is medicalization, which is such a large and influential area of study that it has even become a subdiscipline ("medicalization studies").

Peter Conrad, a sociologist at Brandeis, studied under Irving Zola, who was a pioneer in medicalization studies, and has a new book out on medicalization. Interestingly, he emphasizes that chalking medicalization up to so-called "medical imperialism" is short-sighted, because often times patients and advocates are at the forefront of urging medicalization (alcoholism and adult ADHD being two of the most prominent examples).

This reminds me of a conversation I had with one of my older friends, a tradesman (jack-of-all) who lives on a boat in the river in my hometown. I forget the conversation that lead up to this, but he mentioned to me that for months out of the year he would feel depressed, and then for months he would feel happy. Sure, I thought, cyclic dysthymia! What I told him, though, was that his experience wasn't at all unusual, and that it's only the degree to which this experience interferes with his ability to live and work that makes the difference between a pathology and just the way we feel. He understands his own pattern, what kinds of things make him feel good and bad, and how to deal with the extremes of his existance gracefully. Some people need a little extra help with this and that's ok, but I think the emphasis on "preventative care" definately leads to overmedication and overdiagnosis.

It all reminds me of when I was teaching and teachers were proclaiming that kids were all ADD/ADHD. It was like a catch-all for kids who teachers thought weren't doing well in school, and the teacher needed a label in order to justify his/her actions. Some teachers were like that, not all (before I get trolls jumping on me here).

Now, it almost seems like autism is becoming the new ADD/ADHD. Could it be better diagnosis tools? Hyperawareness like you mentioned with bipolar disorder?

Thanks for posting this. It's good food for thought. :-)

Warm regards,Michelle aka The Beartwinsmommom of twins, one with autismmom dealing with depression

I have had post traumatic stress for 50 years. Yet, they are STILL trying to label me as bipolar! Well, of course, to someone having an hour's look I would appear bipolar because they don't read the literature on TRAUMA. Now this is a big issue for women, and the drug companies sure know how to capitalize on it.

If you do this great website, perhaps a little nudge to read literature on trauma might be of great assistance to people. I also think you might put on CDROMs for cheap that people could get to pass around.

I have been "clean and sober" entirely for twenty years straight and many many before that too; and yet people are STILL trying to get me on addictive medications! Unreal. The Big Pharma rabbit hole is particularly deep. I watch some 30-something come along who's had that ONE HOUR talk with me when I ask for counselling, who's just had a alcohol lunch and then has the gall to propose addictive medications for me and I have to laugh. Why in the world would anyone want their brain turned to MUSH? The weird thing is how hostile they get when I refuse chemical "treatment".

So many people need advocacy NOT chemicals and aren't getting it. The number of young women I meet up here in Canada who have been sold this bipolar bill of goods is STAGGERING and the cost to society is immeasurable. What a hideous legacy is being left to the next generation to deal with! Whatever happened to the concept of HEALING?

OK. I'm playing football (soccer), OK? I score a goal, and go fucking mad, because it's two minutes from time, and it puts my side one goal up, in a cup final. Who wouldn't be pleased?

But my team "switches off," and straight from the restart, the other team equalizes, leading to extra time, when we were within touching distance of a trophy. Now, I'm really low, what a shitty scenario.

This, as I understand it, renders me bipolar? I should be treating both events with complete equanimity. As in "yes, whatever, I scored, but it is, after all, the objective of the game, nothing more," and then "it is a small matter, they have equalized: it is the nature of the game that this is possible".

Fuck me, this sounds like some kind of fucking drama in the filme noir genre: "I light a cigarette, but what does it matter to me? Pah! What is this cigarette, that it should demand that I light it?"! And so on, and so on. What a load of fucking BS!

"... patients and advocates are at the forefront of urging medicalization (alcoholism and adult ADHD being two of the most prominent examples)"

Yes, but I think if Pharma hadn't done such a good job of medicalizing many other conditions, patients wouldn't have necessarily thought of medicalizing these conditions. Also, there is often entanglement with Pharma in these so-called grassroots patient movements.

Other commenters,Thanks for joining the conversation. Interesting points about ADHD and autism. I can't help but wonder how many cases of autism are now "high-functioning autism," a term that I hear about with increasing frequency. Again, perhaps it's a matter of expanding the spectrum, both the bipolar spectrum and the autistic spectrum.

PTSD/Bipolar/Borderline/whatever. I'm not saying that people don't struggle from a variety of mental difficulties, but the everchanging names we attach to problems in the name of "science" is concerning. Today's a little bit overactive becomes tomorrow's bipolar.

Well, I certainly don't mean to exculpate big pharma from the medicalization process. But I do think Conrad's point is important: that laying the responsibility for increasing medicalization solely or wholly at the feet of pharma without considering the role of advocates and patients -- even if they are galvanized and influenced by big pharma, which I am certain they are -- risks missing some important pieces of the overall context.

Great posting. I love the idea of Bipolar Overawareness Week. Recently, Psychiatric Times profiled Dr. Ghaemi and a new task force recommendation that would significantly broaden the diagnosis, including allowing the bipolar depression diagnosis in the absence of a history of mania. Read it here: http://www.psychiatrictimes.com/display/article/10168/1152341

While I respect my friend Nassir Ghaemi, I fear this is going a little too far!

OK, then I think we're in agreement. Patient groups sometimes operate independently of pharma to advocate for more diagnosis and treatment, and pharma also helps to water the grassroots movements when it suits their purposes.

Daniel C,

Thanks. Let's see if we can get a bipolar overawareness movement started! I looked at the link you provided and it made me think that Seroquel in the water supply is perhaps only a few years away. Okay, maybe that's an exaggeration, but I REALLY hope Ghaemi and those who favor expanding the diagnostic criteria read Zimmerman's latest study so that they won't make claims like:

"As a final question, Ghaemi was asked if he believed bipolar disorder is being overdiagnosed. "While unipolar depression, personality disorders, and schizophrenia have each had periods of overdiagnosis, there has never been an era in which bipolar disorder has been overdiagnosed," he said, "no matter what skeptics claim."

He said that concerns about bipolar overdiagnosis are largely anecdotal, have not been empirically well-established, and ignore solid evidence of continued underdiagnosis."

Granted, the Zimmerman study just came out, but some of Healy's writings on the topic have been out for a while, and particularly with child BP there really does seem to be a good deal of overdiagnosis occurring.

Hi,Just to let you know: I'm one of those people with a diagnosis of recurrent depression that lasts months, and with hypomanic episodes that don't meet the DSMIV criteria. Mood stabilising medication is the best thing that ever happened to me after years of antidepressant therapy only. (My hypomanic episodes last 2-3 days). So it's not all total bull.

As one of those patients who may have contributed to the medicalization of my own condition, I have to say that the side affects and withdrawal affects of antidepressants, atypical antipsychotics and benzodiazepines could convince anyone that they were crazy. Add to that the fact that everywhere I looked for info seemed to confirm that my symptoms met the definition of bipolar 2 and if I didn't take the meds, my life would be hell. Now off the meds for the last 2 years, I am starting to recover my soul, my brain, my life. Over-diagnosis of bipolar disorder is a serious, life and health destroying problem.

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About Me

I'm an academic with a respectable amount of clinical experience and no drug industry funding. Given my lack of time, don't expect multiple daily updates. Certain things about clinical psychology, the drug industry, psychiatry, and academics drive me nuts, and you'll probably pick up on these pet peeves before long...